who-managing diarrhea outbreak

8/3/2019 Who-managing Diarrhea Outbreak

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Two types of emergencies regarding acute diarrhoea exist:

Cholera = acute watery diarrhoea

and

Shigella dysentery = acute bloody diarrhoea

Both are transmitted by contaminated water, unsafe food,dirty hands and vomit or stools of sick people.

Other causes of diarrhoea may produce severe illness

for the patient, but will not produce outbreaks which

represent an immediate threat to the community.

First stepsfor managingan outbreak

of acutediarrhoea

THIS LEAFLET AIMS AT GUIDING YOU THROUGH

THE VERY FIRST DAYS OF AN OUTBREAK

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WORLD HEALTHORGANIZATION


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1. Is this the beginning of an outbreak?You might be facing an outbreak very soon if

You have seen an unusual number of acute diarrhoeal cases this

week and the patients have the following points in common:

they have similar clinical symptoms (watery or bloody diarrhoea)

they are living in the same area or location

they have eaten the same food (at a burial ceremony for example)

they are sharing the same water source

there is an outbreak in the neighbouring community

or

You have seen an adult suffering from acute watery diarrhoea with

severe dehydration and vomiting

If you have some statistical information from previous years or weeks verify if

the actual increase of cases is unusual over the same period of time.

2. Is the patient suffering from cholera or shigella?Acute diarrhoea could be a common symptom. Therefore it is important to differentiate

between shigella or cholera in order to improve case management and to estimate needed

supplies

Establish a clinical diagnosis for the patient

you have seen (Table1)

Do the same for the other family members

who are suffering from acute diarrhoea

Try to take stool samples and send them for

immediate analysis. If it is not possible to

send the samples immediately, collect stoolspecimens in Cary Blair or TCBS transport

medium and refrigerate.

Dont wait for laboratory results to start

treatment and to protect the community.

Not all the cases need to be laboratory

confirmed.

TABLE 1

Symptoms Cholera = Shigella =

acute watery acute bloodydiarrhoea diarrhoea

Stool > 3 stools > 3 stools

per day, per day,

watery like with bloodrice water or pus

Fever No Yes

Abdominal

cramps Yes Yes

Vomiting Yes a lot No

Rectal pain No Yes

THE FIRST TWO QUESTIONS ARE:1. Could this be the beginning of an outbreak?

2. Is this patient suffering from cholera or shigella?

Bepreparedtofaceasuddenincrease

innumberofcases

WHO GLOBAL TASK FORCE ON CHOLERA CONTROL


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BOX 1: CHECK THE SUPPLIES YOU HAVE

AND RECORD AVAILABLE QUANTITIES

IV fluids (Ringer Lactate is the best)

Drips

Nasogastric tubes

Oral Rehydration Salt (ORS)

Antibiotics (see Box 6)

Soap

Chlorine or bleaching powder

Rectal swabs and transport medium

(Cary Blair or TCBS) for stool samples Safe water is needed to rehydrate

patients and to wash clothes and

instruments

Collect data on the patients

Note carefully the following data that will help to investigate the outbreak

N Name Address Symptoms Age Sex Date Outcome(5 years) (female F)

1. INFORM AND ASK

FOR HELPThe outbreak can evolvequickly and the rapid increaseof cases may prevent you fromdoing your daily activities

Inform your supervisor about the

situation

Ask for more supplies if needed

(see Box 1)

Ask for help to control the outbreak

among and outside the community

WHAT DO I HAVE TO DOWHEN I SUSPECT AN OUTBREAK?

1. Inform and ask for help2. Protect the community

3. Treat the patients



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2. PROTECT THE COMMUNITY

HOW TO PROTECT THE COMMUNITY

Isolate the severe cases

Provide information

on how to avoid cholera

through simple messages

on the outbreak

Disinfect water sources with

chlorine Promote water disinfection at

home using chlorine

Avoid gatherings

Stool and vomit are highly

contagious

GIVE SIMPLE MESSAGES

TO THE COMMUNITY

To avoid cholera and shigella

Wash your hands with soap

before and after using toilets

before preparing food

before eating

Boil or disinfect the water withchlorine solution

Only eat freshly cooked food

Do not defecate near the water

sources

Use latrines and keep them clean

In case of acute diarrhoea

Start oral rehydration with ORS(see Boxes 2 and 3) before going

to the health centre

Go to the health centre as soon

as possible

PRECAUTIONS FOR FUNERALS

Disinfect corpses with chlorine

solution (2%)

Fill mouth and anus with cotton

wool soaked with chlorine

solution

Wash hands with

soap after touching

the corpse

Disinfect the clothingand bedding of the

deceased by stirring

them in boiling water

or by drying them

thoroughly in the sun


BOX 2: HOW TO PREPARE HOME-MADE ORS SOLUTION

If ORS sachets are available: dilute one sachet in one

litre of safe water

Otherwise: Add to one litre of safe water:

Salt 1/2 small spoon (3.5 grams)

Sugar 4 big spoons (40 grams)

And try to compensate for loss of potassium

(for example, eat bananas or drink green coconut water)


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DONT FORGET


PROTECT YOURSELF FROM CONTAMINATION

Wash your hands with soap before and after taking care of the patient

Cut your nails

ISOLATE CHOLERA PATIENTS

Stools, vomit and soiled clothes of patients are highly contagious

Latrines and patients buckets need to be washed and disinfected with

chlorine

Cholera patients have to be in a special ward, isolated from other patients

CONTINUOUS PROVISION OF NUTRITIOUS FOOD is important for all patientsespecially for patients with shigella dysentery

Provide frequent small meals with familiar foods during the first twodays rather than infrequent large meals

Provide food as soon as the patient is able to take it

Breastfeeding infants and young children should continue

For more information: Cholera web site:

http://www.who.int/emc/diseases/cholera


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If NO

THEN

If NO

THEN

3.TREAT THE PATIENTSSummary of the treatment

A. Rehydrate with ORS or IV solution depending on the severity

B. Maintain hydration and monitor frequently the hydration status

C. Give antibiotics for severe cholera cases and for shigella cases

A. Rehydrate depending on severity

80% of the cases can be treated withOral Rehydration Salt (ORS)

There is NO dehydration:

Give Oral Rehydration

Salt (Box 3)

There is some dehydration:

Give Oral Rehydration Salt

in the amount recom-

mended in Box 4 Nasogastric tubes can be

used for rehydration whenORS solution increases

vomiting and nausea or

when the patient cannot

drink

Monitor the patient

frequently

Is the patient dehydrated?

The patient is losing a lot of fluids because of

diarrhoea and vomiting.

Does he have two or more of the following signs?

The lack of water in his body results in:

sunken eyes

absence of tears

dry mouth and tongue

the patient is thirsty and drinks eagerly

the skin pinch goes back slowly

Is the dehydration very severe?

When dehydration is very severe in addition to the

above mentioned signs :

The patient is lethargic, unconscious or floppy

He is unable to drink

His radial pulse is weak

The skin pinch goes back very slowly

There is severe dehydration

Put an IV drip to start intravenous rehydration

Refer the patient as soon as possible to a higher

level of health care

Otherwise start IV rehydration as shown in Box 5

IF YES, check if the dehydration is very severe

If YES THEN



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BOX 3

When there is NO sign of dehydration:

give ORS solution (see Box 5) after each stool

Child less than 2 years old: 50100 ml (1/41/2 cup)

ORS solution. Up to approximately 1/2 litre a day.

Child between 2 and 9 years old: 100200 ml.

Up to approximately 1 litre a day.

Patient of 10 years of age or more as much as

wanted. Up to approximately 2 litres a day.

BOX 4: THERE IS SOME SIGN OF DEHYDRATION

Approximate amount of ORS solution to give in the first 4 hours

Age Less than 411 1223 24 514 15 years

4 months months months years years or older

Weight Less than 57.9 kg 810.9 kg 1115.9 kg 1629.9 kg 30 kg

5 kg or more

ORS Solution in ml 200400 400600 600800 8001200 12002200 22004000

BOX 5: IV REHYDRATION

Give IV drips of Ringer Lactate or if not

available cholera saline (or normal saline)

100 ml/kg in three-hour period

(in 6 hours for children aged less than

1 year) Start rapidly (30ml/kg within 30 min)

and then slow down.

Total amount per day: 200 ml/kg during the

first 24 hours



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B. Monitor the patientReassess the patient for signs of dehydration regularly during the first six hours

Number and quantity of stools and vomit in order to compensate for the loss of body fluids

Radial pulse: if it remains weak, IV rehydration has to be continued

C. Give antibiotics if needed

When is it useful to give antibiotics?

For cholera cases with severe dehydration only

Ideally for all of Shigella dysenteriae cases, but as a priority for the most

vulnerable patients: children under five, elderly, malnourished, patients with

convulsions

BOX 6: WHICH ANTIBIOTICS CAN BE GIVEN?

Cholera

Doxycycline single dose 300 mg

or Tetracycline 12.5 mg/kg 6 hourly

3 days

Pregnant women: Furazolidone 1.25/mg/

kg 4 times a day 3 daysYoung children: Erythromycin liquid

30mg/kg 4 times a day 3 days

Note: There is increasing resistance of

V.cholerae to Doxycycline,

Tetracycline and TMP-SMX.

Shigella

Nalidixic acid 1g, 4 times a day for 5 days

or Ciprofloxacine 500 mg, twice a day for

3 days

Note: Rapidly evolving antimicrobial

resistance is a real problem.Shigella is usually resistant to

Ampicillin and TMP-SMX.


World Health Organization 2003

This document is not a formal publication of the World Health Organization (WHO), and all rights are reserved by theOrganization. The document may, however, be freely reviewed, abstracted, reproduced and translated, in part or inwhole, but not for sale or for use in conjunction with commercial purposes. WHO/CDS/CSR/NCS/2003.7

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